Valgus Osteotomy and DHS Fixation for Nonunited Femoral Neck Fractures: A Comprehensive Surgical Guide

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Valgus Osteotomy and DHS Fixation for Nonunited Femoral Neck Fractures: A Comprehensive Review

Valgus Osteotomy and DHS Fixation for Nonunited Femoral Neck Fractures: A Comprehensive Review

Intraoperative C-arm lateral view

Nonunion of the femoral neck fracture remains one of the most challenging complications in orthopedic trauma, particularly in young and active adults. While total hip arthroplasty is a reliable solution for elderly patients, it is far from ideal for younger individuals due to concerns about implant longevity, activity restrictions, and the need for future revisions. In this context, valgus intertrochanteric osteotomy (VITO) combined with dynamic hip screw (DHS) fixation emerges as a powerful joint-preserving salvage procedure. This review synthesizes current evidence on the biomechanical rationale, surgical techniques, role of bone grafting, comparative fixation strategies, clinical outcomes, and evolving innovations in the management of established femoral neck nonunions.

Diagnosis and Imaging of Femoral Neck Nonunion

Accurate diagnosis is the cornerstone of effective management. A femoral neck nonunion is typically defined as the absence of radiographic healing signs (e.g., bridging callus, trabecular continuity) beyond 4–6 months post-injury, often accompanied by persistent pain and functional limitation. Clinical suspicion should be high in patients with a history of prior internal fixation who continue to experience groin or hip pain with weight-bearing.

Imaging plays a pivotal role in confirming the diagnosis and planning surgical intervention. Standard anteroposterior (AP) and lateral radiographs of the hip are the initial modalities of choice. These images reveal key features such as hardware failure (broken or backed-out screws), fracture gap widening, sclerosis of fracture ends, and loss of reduction. In the case presented below, AP and lateral X-rays clearly demonstrate a nonunited femoral neck fracture previously fixed with cannulated screws, with visible fracture lines and no evidence of bridging bone.

X-ray of nonunited femoral neck fracture with cannulated screws
Figure 1: Anteroposterior and lateral X-rays of the hip demonstrating a nonunited femoral neck fracture previously fixed with cannulated screws. Note the persistent fracture line and absence of callus formation.

While plain radiographs are essential, they may underestimate the extent of nonunion or associated complications. Computed tomography (CT) provides superior detail of the bony architecture, allowing for precise assessment of fracture orientation, bone stock, and the degree of resorption. Three-dimensional (3D) CT reconstructions are particularly valuable for surgical planning, as they offer a comprehensive view of the fracture geometry and help determine the optimal osteotomy angle and fixation strategy.

3D CT of nonunited femoral neck fracture
Figure 2: 3D CT reconstruction showing the nonunited femoral neck fracture with clear visualization of the fracture gap and prior cannulated screw placement.
CT of nonunited femoral neck fracture
Figure 3: CT slice of the hip joints confirming the nonunion and demonstrating the position of the cannulated screws relative to the fracture line.

Biomechanical Rationale and Surgical Principles of Valgus Osteotomy

The core concept behind valgus osteotomy is not merely angular correction—it is a strategic re-engineering of hip biomechanics to favor healing. Femoral neck fractures, especially those with a high Pauwels angle (typically >50°), are inherently unstable due to dominant shear forces that prevent bone union. By performing a lateral closing wedge osteotomy just proximal to the lesser trochanter, the surgeon effectively increases the neck-shaft angle, thereby rotating the fracture plane into a more horizontal orientation. This reorientation converts destructive shear stresses into beneficial compressive forces during weight-bearing, creating a mechanical environment conducive to bone healing.

Preoperative planning is critical. Weight-bearing anteroposterior (AP) pelvic radiographs are essential to accurately measure the contralateral neck-shaft angle (normally ~135°) and calculate the required correction. The goal is to reduce the postoperative Pauwels angle to less than 25–30°. The osteotomy site is deliberately chosen to preserve the medial femoral cortex, which serves as both a mechanical buttress against varus collapse and a conduit for residual blood supply to the femoral head. While traditional closing wedge osteotomies may result in slight limb shortening, modern sliding or subtrochanteric variants aim to minimize this effect while maintaining frontal plane correction.

Contraindications must be rigorously evaluated. Absolute contraindications include femoral head collapse from avascular necrosis (AVN), while relative contraindications encompass advanced age (>65 years), severe osteoporosis, smoking, morbid obesity, and extensive femoral neck resorption (neck resorption ratio <0.5). In these scenarios, the risks of failure outweigh the benefits of joint preservation, and arthroplasty becomes the preferred option.

Surgical Technique: Step-by-Step Valgus Osteotomy with DHS Fixation

The surgical procedure begins with the patient in the supine position on a radiolucent table. A standard lateral approach to the hip is used, extending from the greater trochanter distally along the femoral shaft. The vastus lateralis is split in line with its fibers to expose the lateral femoral cortex. Under image intensifier guidance, the planned osteotomy site is marked just proximal to the lesser trochanter.

A lateral closing wedge osteotomy is then performed using an oscillating saw. The size of the wedge is calculated preoperatively to achieve the desired correction. Once the osteotomy is complete, the fragments are realigned into valgus, and provisional fixation is achieved with K-wires. The dynamic hip screw (DHS) is then inserted in the standard fashion: a guide wire is placed into the center of the femoral head under fluoroscopic control in both AP and lateral views. The appropriate barrel length is selected, and the lag screw is inserted over the guide wire. A side plate is then applied and secured with cortical screws.

Critically, an anti-rotation screw is placed parallel and anterior to the DHS lag screw to prevent iatrogenic rotation of the femoral head during screw insertion and postoperatively. Autologous iliac crest bone graft is harvested through a separate incision and packed into the osteotomy site and the original nonunion gap. Final fluoroscopic images confirm the correction, implant position, and stability.

Intraoperative C-arm image of valgus osteotomy and DHS fixation
Figure 4: Intraoperative C-arm image showing lateral view of valgus osteotomy with DHS fixstion.
Intraoperative C-arm image during DHS insertion
Figure 5: Intraoperative C-arm image showing AP view of valgus osteotomy with DHS fixstion and packing of autologous iliac crest bone graft into the osteotomy .
Intraoperative C-arm image with anti-rotation screw
Figure 6: Intraoperative C-arm image showing AP view of valgus osteotomy with DHS fixation.
Intraoperative C-arm lateral view
Figure 7: confirming proper placement of the DHS lag screw within the femoral head and doing the osteotomy.
Intraoperative C-arm AP view of final construct
Figure 8: confirming proper placement of the DHS lag screw within the femoral head and finishing the osteotomy.
Intraoperative C-arm image showing bone grafting
Figure 9: Intraoperative image showing placement of the DHS lag screw within the femoral head.

Comparative Analysis of Internal Fixation Methods

Selecting the optimal internal fixation for femoral neck nonunion is pivotal. While cannulated screws (CS) are commonly used for primary fixation due to their minimally invasive nature and lower AVN rates, their performance in revision settings—particularly after nonunion—is suboptimal compared to sliding hip constructs.

Multiple studies highlight the biomechanical superiority of the DHS, especially when augmented with an anti-rotation screw. A prospective randomized trial by Siavashi et al. demonstrated a 0% fixation failure rate with DHS + anti-rotation screw versus 18% with CS in displaced femoral neck fractures—a statistically significant difference (p < 0.001). Moreover, the DHS group showed better Harris Hip Scores and less leg length discrepancy. The anti-rotation screw is not merely an add-on; it is a critical stabilizer that prevents iatrogenic rotation during screw insertion, which can disrupt reduction and compromise healing in vertically oriented fractures.

Finite element analyses further support this approach. In Pauwels type-III fracture models, DHS with anti-rotation screw consistently demonstrates the highest construct stiffness and lowest displacement at the fracture site. In contrast, newer systems like the Femoral Neck System (FNS) have shown inferior performance in high-shear scenarios, with greater gap formation and risk of early failure.

While CS may be suitable for stable, non-displaced primary fractures, the complex biology and mechanics of a nonunion demand a more robust solution. The DHS provides dynamic compression, superior load-sharing, and better resistance to varus collapse—making it the gold standard for VITO in nonunion cases.

Fixation Method Key Advantages Key Disadvantages/Considerations Best Suited For
DHS with Anti-Rotation Screw Superior stability in unstable fractures; lower nonunion rates in revisions; restores alignment and leg length; allows dynamic compression Longer operative time; higher radiation exposure; potential for femoral neck shortening Nonunions, Pauwels III fractures, revision after failed CS
Cannulated Screws (CS) Lower AVN risk; less invasive; shorter fluoroscopy time; lower cost Higher failure/nonunion in unstable fractures; requires perfect reduction; poor for large defects Stable, non-displaced primary fractures in young patients
Gamma Nail + Anti-Rotation Angular stability; good for osteoporotic bone; reduced cut-out risk Limited data in VITO context; potential for femoral head sinking Elderly patients with poor bone quality
Femoral Neck System (FNS) Dynamic angular stability; compact design Inferior stiffness in high-shear models; higher displacement in Pauwels III Basicervical fractures; select stable patterns

The Critical Role of Iliac Crest Bone Grafting

Autologous iliac crest bone graft (ICBG) remains the biological gold standard in nonunion management. Its triad of osteogenesis, osteoinduction, and osteoconduction provides a potent stimulus for healing that synthetic or allogeneic alternatives often cannot match. In VITO, bone grafting addresses two critical gaps: the sclerotic, avascular nonunion site and the fresh osteotomy surfaces.

Clinical evidence strongly supports its use. Baksi et al. reported a 90.1% union rate in 244 patients with neglected nonunions treated with open reduction, DHS fixation, and a composite graft of ICBG plus quadratus femoris muscle pedicle bone graft. Similarly, a prospective study using VITO with impaction bone grafting achieved a 95.5% union rate in young adults. Meta-analyses confirm that combining internal fixation with vascularized or structural bone grafting significantly improves union rates (91.7% vs. 67.7%) and reduces both AVN and nonunion risks by over 75% compared to fixation alone.

While donor site morbidity (pain, sensory changes) is a valid concern, the benefits in this high-stakes scenario are substantial. Emerging alternatives like bone marrow aspirate concentrate (BMAC) offer promise for minimally invasive augmentation, but for large segmental defects or atrophic nonunions, the structural and biological potency of ICBG remains unmatched.

Technique Union Rate AVN Rate Key Insight
VITO + DHS (no graft) 87.5–95.7% 0–11.3% Effective in select cases, but grafting enhances reliability
VITO + DHS + ICBG 90.1–100% 0–5.3% Grafting significantly boosts union and protects against AVN progression
Vascularized Iliac Graft 94.7% 0% Ideal for cases with suspected compromised vascularity
BMAC Augmentation 100% (case reports) Not reported Minimally invasive option for atrophic nonunions

Clinical Outcomes, Functional Recovery, and Complications

Modern VITO with DHS fixation yields excellent functional outcomes in appropriately selected patients. Union rates consistently exceed 85%, with many series reporting >90%. The Harris Hip Score typically improves from preoperative averages in the 30s–60s to postoperative scores in the 80s–90s, reflecting significant gains in pain relief, mobility, and daily function. Patients often regain culturally important activities like squatting and cross-legged sitting.

However, complications must be acknowledged. AVN remains the most serious concern, with reported rates ranging from 0% to 44%—highlighting the importance of strict patient selection. Implant failure (cut-out, loosening) occurs in 5–10% of cases, often linked to technical errors or comorbidities like diabetes. Overcorrection (>145° neck-shaft angle) can increase joint reaction forces and may lead to early osteoarthritis or complicate future arthroplasty. Persistent limping is common despite union, usually due to abductor weakness rather than mechanical issues.

Frequently Asked Questions (FAQ)

For Orthopedic Surgeons

When should I choose DHS over cannulated screws for a femoral neck nonunion?
DHS with an anti-rotation screw is preferred for nonunions, especially those with vertical orientation (Pauwels III), prior hardware failure, or significant displacement. Cannulated screws are better suited for stable, non-displaced primary fractures.
Is bone grafting always necessary in VITO?
While not absolutely mandatory, autologous iliac crest bone grafting significantly improves union rates and reduces AVN risk. It is strongly recommended in atrophic nonunions, large defects, or cases with poor vascularity.
What is the optimal neck-shaft angle after VITO?
Aim for a postoperative neck-shaft angle of 130–140°. Overcorrection (>145°) increases joint reaction forces and may lead to early osteoarthritis or complicate future THA.

For Patients

Will I be able to walk normally after this surgery?
Most patients achieve good walking ability, though a mild limp may persist due to muscle weakness. Full recovery takes 6–12 months, and physical therapy is essential.
How long until the bone heals completely?
Healing typically takes 6 to 9 months. Regular X-rays will monitor progress, and weight-bearing is gradually increased as healing advances.
What are the chances this surgery will fail?
In well-selected patients, success rates exceed 90%. The main risks are nonunion (5–10%) and avascular necrosis (5–15%), which may eventually require a hip replacement.

Conclusion

Valgus intertrochanteric osteotomy with DHS fixation, augmented by autologous iliac crest bone grafting, represents a highly effective joint-preserving strategy for young adults with femoral neck nonunion. By transforming unfavorable shear forces into healing compression and providing robust biological and mechanical support, this technique offers a durable alternative to early arthroplasty. Success hinges on meticulous patient selection, precise surgical execution, and comprehensive postoperative rehabilitation. As techniques evolve—including custom implants and biologic augmentation—the outcomes for this challenging condition continue to improve, preserving native hip function for years to come.

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